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THE NEW YORKER, DECEMBER 7, 2015
practice. Yet the committee, which is-
sued letters of warning to Muizelaar and
Schrot, recognized that both surgeons
had acted with good intentions. Siefkin,
the chief medical o cer, later told an
investigator that Muizelaar was "trans-
parent to a fault." When investigators
for a federal agency criticized the hos-
pital's handling of the procedures, ad-
ministrators defended Muizelaar and
Schrot, while admitting that they had
made mistakes. They wrote, "We ac-
knowledge that two neurosurgeons pro-
vided non-standard, innovative, compas-
sionate care to three patients with a grim
prognosis of glioblastoma multiforme.
The treatment was not experimental."
For a while, it seemed that Muizelaar
and Schrot would emerge from the a air
largely unscathed. In September, 2011,
the I.R.B. barred them from research
activity. Schrot volunteered to attend
a three-day course, sponsored by the
F.D.A., on the proper conduct for clin-
ical trials. Muizelaar did not enroll.
"Partly, I was too busy," he said. "But I
had the audacity to think that I knew
more about clinical trials than anyone
at the I.R.B."The following March, the
hospital adopted a new policy, under
the heading "Innovative Care," which
included strict approval and oversight
requirements. That April, Muizelaar
was named the first holder of the Ju-
lian R. Youmans Chair, endowed by
Youmans himself, the founding chair-
man of the neurosurgery department at
Davis and the editor of a textbook that
remains a standard in the field. Accord-
ing to a press release announcing the
appointment, Muizelaar planned to
use endowment funds "to search for
leading-edge neurosurgical treatments
for brain tumors."
By then,Terri Bradley was dead. De-
spite the remarkable brain scans early
on, her physical recovery faltered. She
remained lethargic and partially para-
lyzed, and had trouble forming words.
The oozing wound in her skull emitted
an unbearable stench. "Walking into
that room, I felt so bad for her roommate,"
Janet said. "I've never smelled anything
worse in my life."
In October, 2011, Muizelaar and
Schrot finally decided to treat Terri's
Enterobacter infection, by removing her
bone flap and flushing the wound with
antibiotics. A month later, she died. She
had lived for a year and a week after the
wound-infection procedure, but to her
daughters the achievement felt hollow.
"It was miserable for her," Janet said.
"She had no quality of life." Whether
the treatment worked, Muizelaar had
no way of knowing. But it did not help.
In July, 2012, a friend of Janet's called
to tell her that her mother's surgeons
were on the front page of the Bee. The
story, one of more than a dozen that the
paper devoted to the Enterobacter pro-
cedures, was a shocking scoop. "A prom-
inent UC Davis neurosurgeon was
banned from performing medical re-
search on humans after he and an un-
derling were accused of experimenting
on dying brain cancer patients without
university permission," it began. (One
reader, in a letter to the editor protest-
ing the coverage, likened the portrayal
of Muizelaar to "a Dr. Frankenstein
clone.") Linda Katehi, the chancellor of
the university, instructed the provost to
open a new investigation and, a few days
later, ordered Muizelaar to step down
as chair. Additional investigations fol-
lowed: by the main hospital accredita-
tion organization, and by the Centers
for Medicare & Medicaid Services,
which excoriated hospital sta for fail-
ing to question the surgeons' conduct.
Among other violations, the agency cited
the unauthorized presence in the O.R.
of Schrot's research assistant, who trans-
ported Enterobacter from the lab inside
a Styrofoam cooler.
"When I found out what really hap-
pened, I was ticked o ,"Janet said. From
an article in the Bee, she learned that
the bacteria implanted in her mother's
brain normally resided in the bowel. "If
they would have told me that, no way
would I have O.K.'d that," she said. She
went on, "Had they done it the legal
way, they might have been onto some-
thing. They should have waited, been
patient, done their research."
In a two-part interview, Terri Brad-
ley's daughters told the Bee that the
Enterobacter surgery had "prolonged her
su ering" and that they were contem-
plating a lawsuit. But Terri's yearlong
survival posed an obstacle, and the Brad-
leys were unable to find a lawyer in Cal-
ifornia who was willing to represent
them. As Alan Milstein, the New Jer-
sey attorney who ultimately took the
case, explained, "There wasn't any evi-
dence that enrolling her in the experi-
ment hastened her demise."
U. C. Davis eventually settled two
Enterobacter suits out of court: the Brad-
leys', for a hundred and fifty thousand
dollars, and one brought by the family
of the third patient, for six hundred
and seventy-five thousand dollars. Pat-
rick Egan's family never considered
suing. In a letter to the Bee, Rabecca
Rich, Egan's widow, thanked Muizelaar
and Schrot for their care of her husband,
writing that "there were no choices left
except hospice and a slow, deplorable
end of life."
By early August, 2013, the Davis
investigations were complete. A report
written by Lisa Ikemoto, a Davis law
professor specializing in bioethics, was
harshly critical. Ikemoto concluded
that Muizelaar and Schrot had vio-
lated the Faculty Code of Conduct by
performing unauthorized research on
human subjects, and that they had
knowingly done so. "The evidence over-
whelmingly establishes that Dr. Mui-
zelaar knew that he did not have the
necessary approvals from the IRB or
the CMO"---the chief medical o cer---
"to proceed with the procedure on Pa-
tient 3, but that he nonetheless did so,"
she wrote. According to Ikemoto's re-
port, when an investigator asked Schrot
why he had not waited for animal data
before implanting Enterobacter in hu-
mans, he told her that the lab work
would take "ten years . . . his entire
career." The investigator described
Schrot's conduct as "reckless." Mui-
zelaar retired, and Schrot resigned.
Muizelaar's home, near Huntington,
is a stately brick Tudor overlook-
ing a rushing creek.When I visited Muize-
laar, last spring, there was a "For Sale"
sign on the lawn---"It's way too big for
me," he said. He moved into the house
last year, after the chair of neurosurgery
at Marshall, Anthony Alberico, a former
resident of his, o ered him a job. "I knew
his character and his skill set," Alberico
said. (Schrot was hired by a private prac-
tice in Sacramento.) Inside, the house
had an unlived-in air. In the living room,
sti -backed chairs appeared undisturbed
by human contact. Apart from a cou-
ple of family photographs, a bottle of
Cabernet signed by Robert Mondavi,